Valsalva Maneuver

What is the Valsalva maneuver?

The Valsalva maneuver is a forceful attempted exhalation against a closed airway. It can be used to clear the ears, unintentionally during coughing or a bowel movement or as a diagnostic or treatment aid.

How it is performed

Instruction: Take a deep breath, close your mouth and pinch your nose with the thumb and index finger and attempt to breathe out gently, keeping your cheek muscles tight, not allowing them to bulge out (Picture 1).

If you are using the maneuver to clear your ears and you feel you need to struggle with it, do not use it, because you may damage your ears.

Picture 1. The Valsalva maneuver

Types of the Valsalva maneuver:

“Do it yourself,” as described above

“Standard” or “quantitative:” blowing out with an open glottis into a tube of a sphygmomanometer against the pressure 40 mm Hg [14]

Unintentional, for example, during coughing or a bowel movement (with a closed glottis–the space between the vocal cords–but with an open nose)

Phase 1. The onset of blowing. The pressure within the chest and abdomen increases and presses upon the arteries in the chest, which results in an increase in mean arterial blood pressure. This activates the baroreceptor reflex, which results in an increase in parasympathetic (vagal) activity and hence in a drop in heart rate. The increased intrathoracic pressure also reduces the amount of blood that comes into the right atrium (decreased venous return or preload).

Phase 2. A decrease of venous return results in a lower amount of blood that is ejected from the heart, which results in a decrease of central venous pressure and consequently in a decrease of mean arterial blood pressure. This activates the baroreflex, which results in a decrease of the parasympathetic (vagal) activity and consequent increase of the heart rate, and in an increase in sympathetic activity, which constrict the arteries (an increase of peripheral resistance), which results in a slight rises of the blood pressure at the end of phase 2 (2b).

Phase 3. Relaxation – the end of the maneuver. The intrathoracic pressure decreases, so the intrathoracic arteries widen, which results in a brief drop in blood pressure. At the same time, the venous blood fills the heart.

Phase 4. The heart ejects the blood into the arterial system against increased peripheral resistance (which has developed in phase 2), so the blood pressure rises again (blood pressure overshoot). This activates the baroreflex, which results in a drop in heart rate (bradycardia). Eventually, both the blood pressure and heart rate normalize.

Chart 1. Valsalva Maneuver

Phase

1

2a

2b

3

4

Intrathoracic pressure

Increased

Increased

Increased

Normal

Normal

Mean arterial blood pressure

Increased

Decreased

Increase*

Decrease*

Increased

Heart rate

Decreased

Increased

Decrease*

Increase*

Decreased

Sympathetic activity

Decreased

Decreased

Increased

Increased

Increased

Parasympathetic (vagal) activity

Increased

Increased

Decreased

Decreased

Increased

References: [5,25,62,68,71] NOTE: Increased and decreased means above the usual level, while increase and decrease mean just a change from the previous level, not necessary going above or below the usual level.

Uses

A variant of Valsalva maneuver is performed against a closed glottis (the space between the vocal cords) with or without a closed mouth and with an open nose. We perform this maneuver unintentionally during coughing, sneezing, gagging, vomiting, bending, sexual intercourse, straining during urination or a bowel movement due to constipation, lifting heavy objects or getting off the bed using arm and upper trunk muscles [5]. The maneuver is also used in sports, such as weightlifting, throwing, rowing, swimming, etc. This maneuver (with an open nose) does not affect the pressure in the mouth, nose, sinuses or ears.

Some coaches recommend using a short (1-2 sec) Valsalva maneuver as a speed accelerator during sprints [63], but there seems to be the lack of reliable studies about its effectiveness.

Valsalva maneuver does not occur during singing [60].

Compulsive Valsalva maneuver has been described in children [73] and individuals with autism [74].

Abnormal connections between the mouth and maxillary sinuses (oroantral fistulas) after a tooth extraction [3]

Primary cough headache [14]

Function of the autonomous nervous system [25,59,62,67]:

An abnormal blood pressure response (for example, an absence of the blood pressure rise in phase 4) suggests an abnormality of the sympathetic system.

An abnormal heart rate response suggests an abnormality of the parasympathetic system.

Valsalva as a Treatment Aid (Benefits)

Valsalva maneuver can help:

Equalize the pressure between the middle ear and the ambient pressure (ear clearing) during scuba diving, driving from a steep hill, elevator descending, parachuting or plane landing [13] or in individuals with Eustachian tube dysfunction (ETD) [44]

Decrease ringing in the ears (tinnitus) [42]; it may increase tinnitus in some individuals [anecdotal reports]

Push the stool out in individuals with neurogenic bowel due to spinal cord injury [29]

Interrupt palpitations (supraventricular tachycardia (SVT), including atrial fibrillation) [32]; the maneuver alone is effective in only 5-25% cases [2,7]; it is also somewhat effective in children [37].

Modified Valsalva Maneuver

Modified Valsalva maneuver is used to terminate an attack of abnormal heart rhythm (arrhythmia) called supraventricular tachycardia (SVT); it includes blowing against a closed glottis followed by lying down face up and raising legs with the help of an assistant [2]. According to one Cochrane systematic review, the modified maneuver may be effective in 19-54% of cases and there is insufficient evidence to either recommend it or advise against it in SVT [79].

Valsalva, Pregnancy and Labor

During pregnancy, the pressure in the abdomen is increased, so pregnant women should avoid exercises that include Valsalva in order to further increase the pressure.

There is insufficient evidence about the benefit of the Valsalva maneuver (purple pushing) during the second stage of the labor [45,46,47,48]. Valsalva during labor may result in a rupture of an eardrum [24].

Valsalva and Stuttering

According to one hypothesis, the Valsalva mechanism may be involved in stuttering, but there seems to be the lack of studies on this topic [18].

Valsalva Dangers

For a healthy individual, a single Valsalva maneuver by using a moderate blowing force is probably not dangerous.

Clearing Ears Dangers

Clearing (popping) ears using a violent Valsalva maneuver during a plane flight or diving may cause a damage of the inner ear and may push unwanted material from the mouth into the middle ear [36,55]. The Toynbee maneuver–pinching the nose followed by swallowing–is considered safer [35] and equally effective [77]. Yawning may also effectively clear the ears [36].

Bowel Movement Dangers

Prolonged straining at the toilet can trigger fainting (defecation syncope) [69]. In individuals with both severe coronary heart disease and constipation, but unlikely in healthy individuals, straining at the toilet may trigger a heart attack. This may occur due to a significant drop in blood pressure and heart rate and artery dilation that result from a combination of Valsalva maneuver and irritation of the vagus nerve in the rectum by the pressure of the stool.

Brain bleeding in individuals with brain aneurysms, heart attack in individuals with heart disease, or stroke in individuals prone to excessive blood clotting (insufficient evidence about the cause-effect relationship) [21,30,31]

Valsalva maneuver was previously believed to increase the trunk stability and strength during resistance (powerlifting) exercises, such as squat, deadlift and bench press, but this has not been confirmed by studies [6,16]. Valsalva maneuver may be equally effective as forced exhalation in maintaining strength during weightlifting [16].

In one study, during weightlifting, the mean blood pressure while using Valsalva was 311/284 mm Hg, and while using forced exhalation, it was 198/175 mm Hg [17]. Blood pressure as high as 480/350 mm Hg during weightlifting using Valsalva has been observed [21].

Valsalva Retinopathy

Valsalva retinopathy [8] means bleeding in front of the retina (the membrane that lines the eyeball and enables vision) due to Valsalva maneuver, for example, during severe coughing, straining on the toilet, blowing musical instruments (trumpet), bodybuilding, marathon running [64], labor or even pregnancy alone [34]. Symptoms may include temporary vision loss and floaters in the visual field [8]. Individuals with idiopathic thrombocytopenia are at increased risk of Valsalva retinopathy [58].

In one study, long-term (occupational) lifting of heavy weight was associated with increased risk of detachment of the retina [27].

Other Side Effects and Complications

Dizziness, vertigo[23] or fainting, for example, during playing brass instruments [43] or in individuals with diabetic neuropathy [25] or spinal cord disorders [61]

Headache. Valsalva maneuver can be responsible for a headache during sexual intercourse, bending or straining at the toilet [14,75], migraine attack [75] or a sinus headache in sinusitis [76]. NOTE: A headache triggered by Valsalva can suggest a brain tumor or other serious disorder with increased intracranial pressure [54,76]

An inguinal hernia (after long-term coughing, straining at the toilet or weightlifting) [78]

From the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, Part 6: Pediatric Basic and Advanced Life Support Circulation

Amazing article. Just had an abnormal valsalva maneuver ANS study and this helped understand why I’m having such extreme symptoms throughout different daily activities. And thank you for all the great resources!

I am a healthy, 56 year old male, developed a-fib 4 days ago. I was scheduled for a procedure to restore normal sinus rhythm. The procedure involved sedation and then an electric shock. My PT told me about the modified Valsalva Maneuver, which is simply doing a head stand, and inhaling / exhaling slowly 10 times, and remaining inverted for 30 seconds.

One such exercise stopped my a-fib and restored normal rhythm, no sedation and shock therapy required. Now I am starting yoga, and doing the headstand once per day, which will decrease to 3 per week.

My husband was constipated and was straining and barring down to try to go and heard a pop. He stopped but within 24 hours ended up with a rash all over his body. The rash went away but he feels his throat/neck has been out of place/alignment ever since this moment. We’ve gone to multiple doctors, specialist, chiropractor and physical therapy to try to fix this discomfort and issue that has spooky been getting worse over the years. Have you heard of this happening?

My dog has been diagnosed with idiopathic seizures. The seizures always have happened as he attempts to vomit up something that is stuck in his throat. I am asking if this could be a result of valsalva maneuver as he stains to expel for example pieces of a bone he picked up and ate quickly on the beach two days earlier. I always believed after he had his first after vomiting up a 4-5 inch wad of a mixture of a scunchi, pine needles n grass. I believe he had no oxygen to his brain. I realize I can’t do anything about it as he eats just about everything n I can’t keep up with it all but I still want to know if the seizure could be a result of the vomiting n not vice versa